Kim Vopni (00:02.038)
Hi, Dr. Aikhurst, Dr. Carly. Welcome to the call. We, as I've said in the intro, we met through, you had been invited to speak at one of my Kegels and Cocktails events several years ago. And then we just recently reconnected at a Mindshare community kind of summit event. And it's been a while since we've touched base, but.
we start talking about UTIs and you were talking about how that is now a main focus of your practice. And I really wanted to invite you on to talk about that because that is definitely something that comes up a lot in my community. And so welcome, nice to see you. Thank you so much for joining me.
Dr Carley Akehurst, ND (00:46.617)
thank you for having me. It's honestly such a pleasure. I love how we've reconnected over these years. think I was pregnant with my son, so that would have been around seven years ago when we initially did that talk. And it's interesting because at that time I didn't talk about UTIs, I actually talked about constipation, but as you well know, it's all related. So I'm thrilled to be here to share my knowledge. I think this information is really important, and so I'm happy to, and I'm grateful for this platform to share what I know.
Kim Vopni (01:10.861)
it.
Kim Vopni (01:16.422)
Yeah, yeah. So can you tell us a little bit about who you are, what you do and how you got into the realm of women's health, but then also what has now led you down to where you're now focusing a lot on the UTI side of things?
Dr Carley Akehurst, ND (01:32.209)
Yeah, absolutely. So I have been an atropathic doctor for over 13 years. I've always had a keen interest in women's health, whether it comes to contraception, perinatal care, or women's mental health. That's always been a passion of mine ever since I was in school. And I think that women's health is an area, not just I think, we know that women's health is an area that's understudied, under researched, underfunded.
under advocated for. And so I'm really passionate about bringing women's health to the forefront. I think we're starting to see this more and more where we're starting to realize just how much inequality there is when it comes to women's health. So initially when I first graduated from school and for the first 78 years of my practice, I focused on perinatal care. So I still am really passionate.
Kim Vopni (02:01.892)
Okay.
Okay.
Dr Carley Akehurst, ND (02:25.949)
about pregnancy and birth and postpartum. But over time, I gradually shifted to bladder care because I realized that there is so much information that is not being communicated to patients that we're way behind in how we offer care to patients with chronic and recurrent UTIs in particular. And that's not for lack of evidence. So we have strong evidence to support a particular view of chronic and recurrent UTIs.
And that's not necessarily being brought into clinical practice in an effective way.
Kim Vopni (03:02.309)
Yeah. And it's interesting because when I started my work, I was very much in that prenatal postpartum world for a number of years as well. And then sort of as my own life stages were progressing to perimenopause and postmenopause, and I had more people coming to me saying, you know, I gave birth 20 years ago, will this still help me? And now like yourself,
It's a whole life journey from a pelvic health perspective, but that menopause transition is such a pivotal time with so little information and so much struggling. It has maybe already been happening kind of subtly, and then all of a sudden we face this enormous transition that uncovers so many other things and there is so much suffering and so little information and education. So UTIs are...
are huge in terms of a problem that a lot of people are dealing with during this time. So I want to talk about like what is UTI, urinary tract infection, what actually is it and what are the contributing factors? Why do we get UTIs?
Dr Carley Akehurst, ND (04:10.013)
Great question. And I'd really like to start by saying that we all likely have heard of a UTI potentially or urinary tract infection. Many women have had one by the time they reach perimenopause or menopause. Some haven't, and that's not necessarily an indicator of whether or not you are likely to develop a UTI issue or a bladder issue during perimenopause and menopause. I'd really encourage your listeners and any
person out there really to think about UTIs in the context of acute UTIs, which means you develop symptoms quite quickly, you maybe have a single episode, you get tested, you get treated, and it no longer becomes an issue. That's an acute UTI. And the difference between that and chronic or recurrent UTIs, where you have an acute UTI and it either doesn't go away completely, or you have another one two months later.
or you have another one two years later, and we get into this cycle or pattern that becomes harder and harder and harder to break. And that area of chronic and recurrent UTIs is where I'm really passionate because that's where we see other factors beyond just acquiring or contracting a bacteria can play a role. And that's where perimenopause and menopause is particularly relevant.
Kim Vopni (05:35.369)
Mm-hmm. Mm-hmm. So.
Okay, so there's the acute and then there's the chronic and the recurrent which you know as we both know that is something that a lot of women are struggling with during this transition. So what is it about perimenopause and menopause that leads puts us into this cycle of the recurrent UTIs?
Dr Carley Akehurst, ND (05:54.459)
Yeah, so when we think about perimenopause and menopause, think many of your listeners, many people out there could probably, you know, have rattle off a few common symptoms, you know, people typically name hot flashes or low libido or hair loss, weight gain is the more common things that we think of when it comes to perimenopause and menopause changes in menstruation. But there are those are all symptoms of this broader hormonal change that happens in the body. And
Kim Vopni (06:09.478)
that.
Dr Carley Akehurst, ND (06:24.109)
almost every body system is influenced by that hormonal change, none the least of which the bladder and the vagina. So we know that as we get closer to menopause, there's typically a drop in estrogen systemically, and that's where we sometimes see things like hot flashes, etc. menstrual changes. But that drop in estrogen also happens locally within the vagina and the bladder.
Kim Vopni (06:36.901)
Okay.
Dr Carley Akehurst, ND (06:51.357)
And you probably come across this in cases of vaginal atrophy, where we see things identified hopefully by a pelvic floor physio or an OB-GYN, where we start to see the structures of the vagina, the vulva, the clitoris lose some of their volume, essentially, and we can have a like a shrinking of the vaginal structures. That is a big indicator of what can happen or linked, I would say, to the
development of chronic hemorrhagic UTIs in peri and menopausal women because that decrease in estrogen actually also causes a decrease in the growth of a good probiotic or a good bacteria or a probiotic called lactobacillus species. So there's sort of a twofold issue happening when we get that decrease in estrogen within the vaginal tissue. One, that tissue becomes less supple, it becomes less robust, it becomes more susceptible to infection.
Kim Vopni (07:30.308)
Okay.
Dr Carley Akehurst, ND (07:49.565)
damage or cuts during intercourse, all of that can promote the growth of not great bacteria. But when it comes to chronic and recurrent UTIs and specifically what's happening within the bladder, it's the decrease in the lactobacillus, that good bacteria that we need to have sufficient estrogen for that to grow, that makes you more susceptible or makes a person more susceptible to infection.
Kim Vopni (07:57.223)
I'm just.
Dr Carley Akehurst, ND (08:16.647)
So for those of your listeners that might not know, lactobacillus is a good bacteria. It's a probiotic. So if you go to the grocery store or the pharmacy and you pick up a bottle of something labeled probiotic, it will typically have one or more strains of something called lactobacillus. There's different strains, lactobacillus, acidophilus, et cetera, but it's really that growth of the lactobacillus overall that we need within the vagina and the bladder to keep away the bad bacteria. Does that make sense?
Making that clear.
Kim Vopni (08:46.984)
Yeah, so I have two questions. Because you just mentioned probiotics, there are, I mean,
Many people are familiar with probiotics from a gut health perspective, and there's different schools of thought on benefit versus not, but that's the oral consumption. But there are also vaginal probiotics that you would insert into the vagina. So could oral probiotics with the appropriate lactobacillus strain be helpful? And or is inserting probiotics specific to the vagina
better or could that help as well? And would it be required for every single person to prevent UTIs?
Dr Carley Akehurst, ND (09:30.383)
Great question. So I would actually say that no, it's not required. And we want to take a step back from that. I'll answer your other questions in a second, but we want to take a step back from that and look at the use of vaginal estrogen. Because vaginal estrogen will help to repair that tissue. It will help to encourage the natural growth of lactobacillus. So lactobacillus that exists within your body already, or lactobacillus that you're getting from food. So for example, from yogurt. If a person is having symptoms,
Kim Vopni (09:46.273)
I'll help you.
Dr Carley Akehurst, ND (09:59.805)
There's sort of a difference between prevention and hoping that you don't get recurrent UTIs or knowing that you're already starting to have some vaginal atrophy, using vaginal estrogen as a good preventative for UTIs, but also for general menopausal support. That's really, really important. And I would argue that that should be first line therapy for anyone who's perimenopausal or menopausal and experiencing UTI symptoms. We have very good evidence around that. And I would say that vaginal estrogen
Kim Vopni (10:18.004)
I.
Dr Carley Akehurst, ND (10:29.733)
without a doubt is the first thing that anybody should be doing. Going back to your other questions, you're absolutely right. It is the Wild West when it comes to probiotics. And there are so many companies out there selling a UTI specific probiotic or a vaginal specific probiotic. There's a difference between prevention in terms of taking the vaginal estrogen and then helping to intervene with somebody who is having chronic and recurrent UTIs.
Kim Vopni (10:44.839)
I'll be right back.
Dr Carley Akehurst, ND (10:57.721)
And that intervention at that level, that's really something that should be guided by a person's naturopathic doctor, primary care provider. If your GP is well versed in this or your OB-GYN is well versed in this, that would be something that you would want to talk to them, to speak to them about before taking a probiotic, either oral or vaginal. In my own clinical practice, when I look at a person who might be having chronic and recurrent UTIs, I'll go through this in a minute in terms of testing.
but usually or typically both an oral and a vaginal probiotic are part of the protocol that I recommend. There are some great Canadian companies out there actually that make probiotics, vaginal and oral probiotics that are specific to the bacteria that we want to see within the vagina. Those two bacteria we typically want to see, both lactobacillus strains are lactobacillus rhamnosus and lactobacillus.
Kim Vopni (11:40.746)
.
Dr Carley Akehurst, ND (11:56.407)
lactobacillus through terry. So you can look for those if somebody's looking for probiotic, but essentially it's something that should be done under the guidance of a well-informed healthcare provider if it's something that we're looking at in terms of intervention.
Kim Vopni (12:10.733)
Yeah. So the other point that I wanted to ask is the decline in estrogen also changes the pH of the vagina, which in and of itself is also part of why we are more prone to infection. Is that accurate?
Dr Carley Akehurst, ND (12:25.809)
That's absolutely accurate. that's essentially the link between the decrease in estrogen and the growth of lactobacillus. So we need the estrogen essentially to keep the pH at a level that will allow that lactobacillus to grow. What's interesting about that too is that we need that estrogen to help us keep an appropriate pH because too high a pH and you can have what we call opportunistic bacteria overgrow, too low a pH and you can actually get a
an overgrowth of lactobacillus, which can lead to a condition called cytolytic vaginosis, which mimics, often mimics yeast or yeast infection. So that's again where it's important to not just to start taking a lactobacillus without looking at the context of what's going on for a person specifically.
Kim Vopni (13:13.014)
Yeah. And how would you, so you just mentioned something that could present as a UTI that is not. So how do you test to determine is it an overgrowth, a yeast, or is it a UTI?
Dr Carley Akehurst, ND (13:26.235)
Yeah, so this is a bit of a, well, I would say it's, the evidence is changing currently and what's done in terms of clinical practice and what's done in terms of best evidence, there's a wide gap between them. So currently in British Columbia and from my understanding through most of the rest of Canada, what is standard of care at the moment is to do what's called a urine culture and sensitivity for a person that's presenting with UTI symptoms. So you start to feel some UTI symptoms, whether it's burning on urination,
Kim Vopni (13:48.091)
I.
Dr Carley Akehurst, ND (13:56.397)
an unusual smell to the urine, increase in frequency or urgency or sometimes incontinence. You present your primary health care provider. Your primary health care provider will usually do what's called a urine dipstick in office. So that's just a quick urinalysis to look for typically white blood cells to check for infection, a number of other markers. And then they also, if that sample is positive for white blood cells, they'll typically send you to the lab to run something called a urine culture and sensitivity.
And this is where we run into problems. So urine culture and sensitivity was a wonderful test when that was all we had. It was developed originally in the 1950s and it's changed a little bit, but it hasn't changed a lot. Originally when urine culture was developed, it was developed to check for the presence of E. coli, so a bacteria that's known to cause bladder infections. However,
Kim Vopni (14:44.474)
.
Dr Carley Akehurst, ND (14:49.925)
We are 70 years past that and bacteria are getting smarter. We're in the post-antibiotic era in terms of how bacteria are starting to become resistant to antibiotics and how they behave. We know now that there's evidence to show that most UTI symptoms, especially when it comes to chronic and recurrent UTIs, the bacteria travel in groups. So when we are only reporting as culture does,
Kim Vopni (15:09.977)
Okay.
Dr Carley Akehurst, ND (15:18.757)
a single bacteria. So we do the test, the test comes back and it says, this was an E. coli infection, or this was a klebsiella infection, for example. It really is leaving a lot of information on the table. If this is an acute UTI, that typically would warrant, you know, anywhere between three and seven days of an antibiotic. Hopefully the patient doesn't have any symptoms after that. And then that's the end of it.
Kim Vopni (15:37.956)
Okay.
Dr Carley Akehurst, ND (15:45.627)
However, if we're dealing with chronic or recurrent UTIs, we need to know more than just one single bacteria that are there. We need to know what's happening within the microbiome of the bladder so that we can properly look, is there a bacteria there that's known to cause other bacteria to join it? And are we treating the single bacteria that was identified there with a broad spectrum enough antibiotic to capture all of the bacteria that we're seeing in that?
Kim Vopni (16:10.043)
Okay.
Dr Carley Akehurst, ND (16:15.503)
in that test. What's tricky clinically at the moment is that that type of testing that gives us a more thorough report, it's called PCR, DNA PCR testing. At the moment, that is only available in the US and it's expensive to do it. So that is a test that would really only be available through a naturopathic doctor, a functional or integrative doctor, someone who is a little bit more versed in the world of what we call the Euro biome or the microbiome of the bladder.
So it's a bit tricky at the moment.
Kim Vopni (16:46.554)
Got it. There's biomes everywhere, right? Like, your uro biome is strobilome, the gut microbiome. It's crazy how many biomes we have. when the gut microbiome terminology, I know I'm taking a bit of a tangent, but when that first came out,
Dr Carley Akehurst, ND (16:50.491)
Yep, there are.
Dr Carley Akehurst, ND (17:00.914)
Yeah.
Kim Vopni (17:01.846)
It was super interesting and still a lot of people talking about it and now just how many others, and it makes sense. So we would have them everywhere given how many bacteria we have in our bodies. okay, so limited in Canada, available in the US, but only if you're working with a practitioner who would have access to that. It's not the standard sick care system practice. so basically, if I understand correctly, there's a lot that's missed.
There's a lot that's missed in terms of like, and some people may not even get the appropriate diagnosis. No, you don't have a UTI, even though maybe they do because the presence of that they haven't tested for the presence of other bacteria. Is that correct to say?
Dr Carley Akehurst, ND (17:43.269)
It's correct. And it's tricky because often that patient, when the urine culture comes back negative, that patient will be given a, usually referred to a urologist if they have persistent symptoms, offered a cystoscopy. And then if nothing's visible on the cystoscopy, they'll usually be given a diagnosis of interstitial cystitis.
Kim Vopni (18:02.565)
Crazy. Okay, so for those of you that don't know the terminology of interstitial cystitis, I see sometimes called bladder pain syndrome. have several episodes about that as well, but that's crazy. didn't realize that would happen. that's a whole other... So then now, like...
Dr Carley Akehurst, ND (18:03.815)
Mm-hmm. It is.
Kim Vopni (18:22.355)
my mind's racing now because so people are gonna get this other diagnosis and then they're gonna go down the rabbit hole and then they're maybe gonna be treating something that is the improper treatment because it's not actually IC that they have.
Dr Carley Akehurst, ND (18:32.838)
It's infection.
Kim Vopni (18:34.613)
Crazy.
Dr Carley Akehurst, ND (18:35.685)
Isn't it mind boggling when you start to see that, which is why going back to sort of my transition from perinatal care, when you start to see it, you can't unsee it. And when you start to test and treat, it's really mind boggling. And you realize how many women are suffering with this worldwide with a misdiagnosis, with potentially incorrect medication and treatment, when what they actually have is infection.
Kim Vopni (19:02.999)
Wow. Okay, so how do you, given that you're in Canada,
you have this limitation from a testing perspective. How do you then, how do you navigate that? How do you help that person when you might get what you could interpret? It could be accurate, but it could also be inaccurate information from any of the testing that you're doing.
Dr Carley Akehurst, ND (19:22.011)
Yeah, so you have when I work with a patient who has chronic or recurrent UTIs, I like to think about looking globally at what's going on with them. And I might this is where health history is so important. So usually my intake is about an hour because I want to know all the details of how did this start? When did this start? Is this something that's shown up in perimenopause or menopause? And usually if it is a patient who or a person where this is starting to show up in menopause, I'll do three months of vaginal estrogen before I do anything else.
Kim Vopni (19:43.187)
.
Dr Carley Akehurst, ND (19:51.261)
before I do any testing, before I do anything else, three months of vaginal estrogen and potentially a probiotic is usually my standard. The other piece that I will say about this, and this is kind of a side note, but it's actually really important. Having sufficient vitamin D levels is also critically important to ensure that your immune system is strong enough to keep a balance in the urobiome. So any patient that comes into my practice, the first thing that we do is test vitamin D.
And I often get questions about this because patients will say, well, I take vitamin D or I don't need to test. It's 70, in the neighborhood of $75 to test and it's not covered by the MSP systems with private pay for patients. But I need to know what your vitamin D level is because if you are less than a third of the minimum baseline, we need to correct that before we do any fancy testing or anything else.
The reference range for vitamin D levels in BC is 75 to 250. And what I know clinically is that patients will often become symptomatic within their bladders if they have chronic and recurrent UTIs, if they're below around that 125 mark. So that's my standard is that I want to see patients at bare minimum between 125 and 150 on their vitamin D test before we sort of proceed to the next piece.
Kim Vopni (21:11.441)
Okay.
Dr Carley Akehurst, ND (21:15.527)
So for any of your listeners, I would say that's who are suffering with bladder symptoms, take a look at your vitamin D. That's really important. And I can't speak to specifics around dosing, but working with an integrative practitioner, an antidepressant doctor who can help you safely look at vitamin D dosing to bring up those levels because being a fat soluble vitamin, you can actually take too much vitamin D. So it's important to work with a practitioner who can help you come to that proper dosing.
Kim Vopni (21:36.016)
Okay.
Dr Carley Akehurst, ND (21:44.925)
conclusion for you. So I would say that back to the perimenopause and menopause piece, three months of vaginal estrogen is kind of the standard. That's really important. I often get questions around vaginal estrogen dosing, if it's safe to take and if we need to be considering a person's health history. Yes, that is important, but we know that with the dosing and application of vaginal estrogen,
Kim Vopni (22:05.167)
Yeah.
Dr Carley Akehurst, ND (22:13.817)
it's not systemically absorbed in the standard amount that we typically prescribe for vaginal atrophy or genitourinary syndrome of menopause. So hopefully that puts some people at ease knowing that it's a generally very safe medication to use and can be hugely effective in stopping that cycle. I think it's really important.
Kim Vopni (22:34.38)
Yeah, I jokingly say, I know it's not a nutrient, but I jokingly say that vaginal estrogen is an essential nutrient once we reach menopause for the rest of our life. Yeah. And I talk a lot about vitamin D too, but I didn't think of it from that perspective. So that's super interesting and really, really helpful. Thank you for sharing that.
Dr Carley Akehurst, ND (22:42.203)
No, totally. Yeah, so.
Dr Carley Akehurst, ND (22:52.605)
You're welcome. In my clinically joke about vaginal estrogen as being vitamin V. Yeah, it's just really, I will speak about this till the end of time because I really feel that for chronic and recurrent UTIs in perimenopausal and menopausal women, vaginal estrogen should be absolutely first line standard of care without question. And I see clinically in the area where I practice, that is not happening at all, right?
Kim Vopni (22:57.262)
Yeah.
Kim Vopni (23:04.515)
Yeah.
Kim Vopni (23:20.301)
Yeah. Yeah.
Dr Carley Akehurst, ND (23:22.511)
If we link that back to the piece around Euro biome balance and knowing about that lactobacillus, current standard of care, what I see often is that even with genitourinary syndrome of menopause, many of those patients are being offered repeated short courses of antibiotics, which only further disrupts the urinary microbiome, let alone the microbiome in other areas of the body. And I really feel perpetuates that cycle.
Kim Vopni (23:26.733)
Okay.
Kim Vopni (23:51.373)
Yeah, yeah, it's, again, I'm gonna go on a bit of a tangent, but I do talk about this quite a bit and I know that you would be on the same page as myself, but with all due respect to medical doctors, they are trained within a sick care system and we need those sick care
trained practitioners for certain situations. However, when we think of they are considered the healthcare, really I think the terminology should be that's the sick care yourself, functional medicine practitioners, integrated practitioners is really the healthcare. And when you were also talking about the vitamin D, the ranges, there's a sick care range, and then there is an optimal, which is typically what naturopaths or functional medicine or integrated practitioners will use where
they're taking out the population that is the unhealthy included in that reference range and really what is considered the best, which you just outlined from a Eurobio perspective, that 125 to 150, I believe is what you said. it really like, I don't know, but I think back in like when medicine was first coming around, it was probably more so the integrated practitioners. was very much a root cause and...
And then we have gone so far away from that. And I don't want to get down the political side of things, but I want people to also take from this conversation that there are other people who can be a part of your health care team that will provide value in other ways. And I think it does cost out of pocket right now, which is unfortunate. And the vitamin D piece that we have to pay for that, knowing how much research about so many aspects of health care.
why we have to pay privately is absolutely ridiculous. Again, a whole other conversation, but yeah, yeah, it's, frustrating, but okay. So, as you said, standard of care right now, use your practices to first line of defense, vaginal estrogen. And I also hear weekly, daily from people I've been on X number of rounds of antibiotics and never have they been ever offered.
Dr Carley Akehurst, ND (25:38.299)
Yeah.
Kim Vopni (26:01.896)
vaginal estrogen and it just is absolutely crazy to me. So they're now offered the recurrent antibiotic use as you say short course, which is now also disrupting the biomes. Is there like if somebody has an active UTI, it, is there ever a situation where somebody would not need a.
antibiotics or will there would they always need antibiotics and if they do need antibiotics how do you then support the biomes because of that insult from the antibiotics?
Dr Carley Akehurst, ND (26:39.485)
Great question. I was at a lecture in 2023 by a medical provider from LifeLabs actually who was talking about antibiotic use resistance and looking at trends around the world in terms of how people treat things. We know that in some countries of the world, acute UTIs are not always treated with antibiotics. There are other supportive measures that are recommended, drink more water, rest.
Kim Vopni (27:02.313)
So.
Dr Carley Akehurst, ND (27:06.429)
Avoid alcohol and sugar, that type of thing, and not giving an antibiotic prescription. Maybe the provider writes the prescription and says, you're not better in a couple of days, take this. Similarly to my standard of care for strep throat, for example. Or sorry, not strep throat, ear infections, for example. So yeah, give the prescription and say, listen, if you're not feeling better, you can start this. But generally trying to avoid having the patient take that.
Kim Vopni (27:22.824)
you
Dr Carley Akehurst, ND (27:34.141)
In this case, they were actually using the example of strep throat, but in some places in the world, I typically am a bit more aggressive with strep, so I usually will treat with an antibiotic, but in some places of the world, there is a watch and wait procedure that happens. The challenge with UTIs, especially with acute UTIs, is that they can, a UTI in the bladder, bacteria in the bladder, can travel to the kidneys.
Kim Vopni (27:54.595)
you
Dr Carley Akehurst, ND (27:59.469)
And that can be really problematic. So the name for an infection that has traveled to the kidneys is pylonephritis. Typically, the symptoms are much more extreme. So we see fever, we see significant low back pain. Sometimes there can be blood or pus in the urine. And that's a really big concern. And so I don't necessarily encourage not treating a UTI. I do have patients who refuse.
Kim Vopni (28:21.638)
Okay.
Dr Carley Akehurst, ND (28:26.993)
completely to take antibiotics and so then we look at antimicrobial herbs to treat UTI. But if we're talking about an acute UTI that turns into chronic, perhaps in a non-menopausal patient, we need to look beyond short course antibiotics or short course antimicrobials. Because when a person, most of the time I would say patients in my practice have been dealing with their UTI symptoms by the time they get to me,
Kim Vopni (28:50.374)
Okay.
Dr Carley Akehurst, ND (28:56.335)
at least six months, sometimes two or three years, sometimes 30 years. What we know about bacteria, how they behave, is the bacteria over time can actually become embedded in the bladder wall. And so a short course of antibiotics isn't really going to touch that. But it's not standard of care currently to give long term high dosing antibiotics, even in that case.
So in my practice, just taking you kind of through those steps, the first thing is either vaginal estrogen or vitamin D or both. Then we look at the PCR testing and that testing can be quite useful because it'll report the bacteria that we see there in the uro biome. And I'm typically looking for bacteria that are known to cause UTIs. I'm looking for good bacteria, but I'm also looking for bacteria that are known to embed themselves in the bladder wall.
and cause something called a biofum. So with the company, the testing that I do, we actually look both at the bladder and the vagina in women and the bladder, and we do a semen sample in men to see if we can take a closer look at what's happening there. But that allows me to get a good understanding of what's happening with the microbiomes of the vagina and the bladder. And then with the, if that testing is ordered by a licensed healthcare provider,
Kim Vopni (30:13.892)
Yeah.
Dr Carley Akehurst, ND (30:19.569)
The report also includes antibiotic recommendations where they have looked for resistance genes within the bacteria that they've found. And I find that actually is really important because if I'm going to prescribe an antibiotic, whether it's short term or long term, I need that information whether or not it's going to be effective for that patient.
Kim Vopni (30:41.997)
Can I just clarify you? You mentioned that the PCR testing was only available in the US, but then you said you do PCR testing. So can you clarify what you use?
Dr Carley Akehurst, ND (30:51.067)
Yeah, so I used testing out of the US. So I don't, yeah, they do like.
Kim Vopni (30:54.113)
I see. okay. we can still, Canadians can still access, of course we have to pay for it, but you're meaning it's shipped off to the U.S. and then, okay, got it.
Dr Carley Akehurst, ND (31:03.237)
Yeah, so there's no Canadian company and with that, it means that well, there's barriers to securing that through the conventional system. It would really only be able to be available through an integrative or a naturopathic doctor. Someone who's, yeah.
Kim Vopni (31:05.677)
Got it.
Kim Vopni (31:18.275)
Got it. for clarifying that.
So many questions I want to keep going back to. Are there people, so we've talked about kind of the perimenopause menopause population as that is going to increase our risk for basically not solely, but a lot of it is the loss of estrogen. But are there other people who are more prone to, for other reasons, getting UTIs?
Dr Carley Akehurst, ND (31:48.635)
It's a really good question and it shines a light on a really important aspect of this. So yes, but I couldn't say that, you know, this patient over here is more likely than that patient without knowing what their vitamin D is like. Do they have IBS or digestive issues? Do they have autoimmune disease? Is there a family history of UTIs? Have they had a UTI before? All of those pieces. One of the main questions that I get in practice is can I get a UTI from my partner?
And the current medical evidence would say no, but in terms of what we know about bacteria, I would argue absolutely. And I have seen it in practice where a patient will say, have a new partner and every time we have intercourse, I get a UTI. I'm triggered by UTI. That's commonly treated by giving a single dose of an antibiotic, what we call postcoital.
Kim Vopni (32:41.957)
Okay.
Dr Carley Akehurst, ND (32:46.617)
after intercourse, somebody, the prescriber will say, take an antibiotic each time that you have intercourse. That can be helpful for symptom management, but we're not really getting to the root cause when we treat that. Often in practice, I'll treat or I will at the very least test both partners because if somebody is being triggered every time they have intercourse and they've had a full assessment, there's no structural abnormality and we're, it's,
Kim Vopni (33:12.125)
Got it.
Dr Carley Akehurst, ND (33:16.321)
something that we can see from their PCR testing that they have a bacteria there. It might be that their partner doesn't have any symptoms because they have sufficient vitamin D, they have a really robust microbiome, they don't have IBS, their stress is really low, they eat really healthy and they have no pelvic floor issues.
And the.
Kim Vopni (33:37.6)
So sorry, you would then treat both people even if the other person doesn't have symptoms.
Dr Carley Akehurst, ND (33:43.351)
if depending on what their PCR testing says. So let's say we find enterococcus fecalis on a person who is symptomatic with having UTI symptoms. And we've treated them and enterococcus fecalis is quite stubborn. So let's say it won't go away. And the patient reports, I'm triggered every time after intercourse and no matter what I've done, will occasionally, if it warrants it, test the person's partner.
and see if they happen to be a carrier for enterococcus fecalis as well. And in that circumstance, I will treat both partners. And I've had really good success with that because no, sounds like I'm tooting my own horn, but like nobody else is really looking at that, right? And if we're still stuck at the point where we're still doing urine culture, which doesn't even give us enough information. So when we're thinking that we need to be doing PCR, we need to be looking at PCR for both.
Kim Vopni (34:22.064)
Got it. Okay. Yeah.
Kim Vopni (34:31.655)
Yeah, yeah. Yeah, yeah. What about things like there's several different companies that will offer cranberry based supplements. There's D-Manos.
Dr Carley Akehurst, ND (34:42.877)
both sexual partners, right?
Kim Vopni (34:57.918)
boric acid. Do any of those play a role in managing, preventing, treating of UTIs?
Dr Carley Akehurst, ND (35:08.509)
Yeah, a fabulous question and one I get all the time. Yes and no. So I would say that if you're a person that has recurrent UTIs, you're not peri or menopausal, you just want to know how do I stop this? Typically, what happens is a person will go to a pharmacy, they'll be recommended D-Man Oaks and or a cranberry supplement. Cranberry doesn't have great evidence behind it. I don't use it a lot in my practice. If patients want to take a cranberry, I don't think there's any harm in it.
Kim Vopni (35:32.669)
you
Dr Carley Akehurst, ND (35:37.565)
But I actually don't think it's all it's cracked up to be. D-Manos on the other hand is a really interesting one because there was a study that came out maybe nine months ago that said that D-Manos was ineffective in the prevention or management of UTIs. However, I find in my practice, we need a minimum dose of 4,000 milligrams or four grams per day of D-Manos to be effective. The study only looked at one and 2000 milligram dosages.
So what D-Manos does, it's a sugar that's very attractive to bacteria. And when you take it orally, what it does is it encourages the bacteria to sort of uncouple from the bladder wall attached to the sugar instead, and then it's urinated out. And so I actually think it's a phenomenal product. And I think that at that 4,000 or four gram dosing, it can be really beneficial both in prevention and in treatment.
Kim Vopni (36:28.586)
.
Dr Carley Akehurst, ND (36:35.793)
And I usually, I will often use it in conjunction with antibiotics. Dimanos, the best evidence to show that it's effective against E. coli, but I actually feel strongly that it's beneficial to all types of bacteria. There was a small study that showed that it was effective against Klebsiella, another bacteria that causes UTI symptoms, but almost, I recommend it to almost all of my patients. What's tricky, two pieces. One, it's hard to find a product that's
that high dose, four grams or 4,000 milligrams in Canada. There is one that is recommended by a naturopathic doctors often. And there is one product in the US that's five grams or 5,000 milligrams. The other piece about that too, again, it's something that should be done under the guidance of a naturopathic or functional doctor because when D-mannose encourages that uncoupling of bacteria from the bladder wall, it does the same in the intestine.
Kim Vopni (37:21.518)
.
Dr Carley Akehurst, ND (37:33.117)
So it can cause diarrhea, it can cause a bit of stomach cramping, especially at that higher dose if you're not, so you want to be under the care of somebody that knows what they're doing, just to be able to ask questions and come up with creative solutions around dosing.
Kim Vopni (37:49.574)
And then boric acid, that's more for like BV bacterial vaginosis, not so much for UTIs, is that correct?
Dr Carley Akehurst, ND (37:56.061)
Not so much for UTIs, but it helps to reset the vaginal microbiome by lowering the pH and encouraging the growth of lactobacillus. So it's all the same, right? When it comes down to managing essentially the microbiome of the female reproductive and urinary tract. I'm a huge fan of boric acid because I think when we look at it compared to some of more of the pharmaceutical options, it tends to have
Kim Vopni (38:13.033)
Yeah.
Dr Carley Akehurst, ND (38:22.781)
pure allergic reactions, tends to be a little bit better tolerated by many patients. And I love the idea that it supports encouraging that appropriate pH, which encourages the growth of lactobacillus. And that coupled with a vaginal and or an oral proleotic can be hugely effective in supporting healthy microbial balance within the vagina, which also then influences the bladder.
Kim Vopni (38:49.085)
Got it. I want to wrap up with the end on the estrogen piece, but I have one other question. You mentioned IBS and autoimmunity that you look for that in the health history. So is there a link between people who have IBS or an autoimmune condition being more prone to having UTIs?
Dr Carley Akehurst, ND (39:03.581)
IBS, yes. And we know that from the literature that there is a connection between IBS and UTIs. Autoimmunity is a little bit more tricky, but I see that clinically in my practice. And the autoimmunity piece is just when you think, when one thinks about chronic or recurrent UTIs, I encourage you to think about it from a microbiome perspective. What's happening at that base level of the microbiome?
Do I have enough good bacteria to keep the bad bacteria at bay? With autoimmunity, what I see in practice is often people who have an autoimmune disorder essentially means that the immune system is overreacting to base stimuli. And that can usually or sometimes be an indicator of a microbiome disruption. And that's sort of the connection there. A few years ago, a number of years ago, there was a theory of interstitial cystitis or recurrent UTIs.
called the gag layer theory, which has since generally been disproven. But again, that was sort of an immune overreactivity within the bladder. With any patient with what we call a concomitant condition, so like if you already have a thyroid disorder, you already have an autoimmune disease, you already have IBS, I would really encourage someone to look at their UTIs in that context. What's at the piece, what's the part that kind of ties it all together?
Kim Vopni (40:28.286)
huh.
Dr Carley Akehurst, ND (40:29.773)
And when I originally when I initially sit with a patient, I often talk about an umbrella, right? So your microbiome is at the top of the umbrella and it influences hormones, infection, recurrent UTIs, mood, all of these other pieces. And it's really important when, again, going back to that hour long initial visit, to figure out a person's health history to try and determine, you know, are these UTIs a hormonal issue? Does this person need vaginal estrogen? Is this an embedded infection?
Is this an acute infection? Is this related to what's happening with autoimmunity? Or is this a case of constipation and the UTIs are secondary to the pelvic tension that's coming from being chronically constipated? So it's important to sort of look at all of those avenues.
Kim Vopni (41:17.403)
Yeah. Okay, so I'm going to end off on the vaginal estrogen piece. both are, we preach the vaginal estrogen. There's different types of estrogen. Estriol, estradiol, estrone are the three main types. And in Canada, the only estrogen cream that we have that would be
through Health Canada would be estrogine, is an estrone. It's not estradiol, not estradiol. There's Bi-Est creams, which would be a little bit of both. There's Vagifem as a tablet, which would be estradiol. So what is your, based on the evidence, what is your recommendation for potentially the best delivery of estrogen? When we think about it in the UTI perspective,
Obviously there's other benefits to the estrogen, but from a UTI prevention or keeping the lactobacillus happy, is it best for a tablet with estradiol? Is bias better, internal, external, E-string, or is estrogine from an estrone derivative better?
Dr Carley Akehurst, ND (42:25.597)
Great question. Estrone is not my favorite, really, for anything. I don't love it. also don't, mean, Vagifem I do prescribe if patients prefer a tablet just from an ease of use perspective. I typically dose this in a patient using their estrogen vaginally every night for two weeks and then every two to, or two to three times a week, kind of on an ongoing basis, depending on the patient's needs. However,
Kim Vopni (42:29.682)
Mine neither. Yeah.
Kim Vopni (42:49.746)
you
Dr Carley Akehurst, ND (42:53.253)
I don't love the tablet because I love to see some of the cream being used on external structures as well. And so often I will compound a vaginal estradiol. Typically that can be expensive for patients. so depending on their coverage and depending what they want, I will either compound either a biassed or an estradiol, but that's typically my favorite. I would rank them sort of like a compounded estradiol or biassed, then a vagifem and then estrone.
Most of what I see prescribed conventionally, unfortunately, is Estrone. And it's just, I just think it's not, we can do better. That's what they will say. We can do a lot better.
Kim Vopni (43:32.99)
Yeah. Yeah. And I don't know, I don't know this. I should know this. I should dive into it. Most of the research with regards to vaginal estrogen is estradiol, sometimes with estriol. I don't know of any research about estrone. Have you seen any?
Dr Carley Akehurst, ND (43:48.669)
I agree. No, no. And the other piece that I'll add to that too, is that I also am a huge fan of hyaluronic acid moisturizers as well. And so the feel amazing like shout out to Shirley, like I really, I will often recommend that in between a vaginal estrogen if someone's really struggling. And or just in general, I think it's a phenomenal product.
So I think that we do have way better options out there as opposed to Estrone. And I would prefer to see someone on a Vagifem versus an Estrone cream.
Kim Vopni (44:25.838)
Yeah, yeah, I agree with that. And what about vaginal DHEA? So not in and of itself estrogen, but can help with our own body's conversion. Does that play a role and could that help from a lactobacillus perspective or UTI prevention perspective?
Dr Carley Akehurst, ND (44:43.225)
It's a really good question. So vaginal DHA is, or DHA in general, is federally regulated in Canada. So it's not something that I see commonly prescribed because it's out of the scope of naturopathic doctors. It's not something I prescribe. However, I would argue that anything that increases the local estrogen level within the vagina will help to essentially encourage that growth of lactobacillus.
Kim Vopni (45:05.143)
Yeah.
Dr Carley Akehurst, ND (45:06.459)
I also think too that the evidence isn't as strong for DHEA versus we have so much evidence to show the safety and efficacy of vaginal estrogen. And to me, it's typically very well tolerated. It's other than people don't love applying something even twice a week vaginally, which is why the tablet I think can be so popular. But to me, yeah, like a straight vaginal estradiol is usually my go-to.
Kim Vopni (45:35.875)
Yeah, yeah, just because there's going to be some people listening, the conversation with estrogen will always come with a question of what about I'm a breast cancer survivor or I have breast cancer or I have cancer in my family.
I've written an article to share some of the research. Can you just add a quick little tidbit about estrogen and cancer?
Dr Carley Akehurst, ND (45:56.049)
Yes, so vaginal estrogen is not systemically absorbed. It is okay to use if you have a history of cancer. I will say that with the caveat of always speak to your care provider and whoever's prescribing it for you. But there is reasonable evidence to show that this is a safe thing to do, that vaginal estrogen not being systemically absorbed is not a concern in cancer survivors. I often encourage my patients to think about vaginal estrogen like face cream for your vagina.
Kim Vopni (46:24.826)
Yeah.
Dr Carley Akehurst, ND (46:26.385)
Like it's really, it's not using a systemic estrogen to address menopausal symptoms. It's really just locally to support those tissues and structures in the vagina. And it's dosed as such. So it can be safely used in just about everybody.
Kim Vopni (46:40.853)
Yeah. Yeah. Yeah. Thank you for that. This has been so informative. Thank you so much. Where can people find you and learn more about your work and potentially even work with you?
Dr Carley Akehurst, ND (46:53.853)
Yeah, thank you. So I own a naturopathic clinic in Vancouver in the South Granville neighbourhood. We have 12 naturopathic doctors, three of whom are menopause society certified. Right now I have two doctors that are covering my clinical practice for the chronic and recurrent UTI piece. So we have people there seeing patients.
who have been trained and are hands-on measured by me. I'm doing more oversight of clinical cases and then running the practice at the moment. But our clinic is called Clementine Natural Health. And yeah, we'd love to see you. For patients who or people who don't reside within the province of BC, because those are the restrictions from our regulatory college, can only see, we can only see patients who live in BC, I've created a Chronic and Recurrent UTI protocol.
called the ACRS protocol. And with the ACRS protocol, it's essentially a module based program, self study program where I provide all of the information, including the testing that I use and support for that, for someone to be able to take that information and work with a local healthcare provider to get the care testing and prescriptions that they need. But that's called the ACRS protocol for anyone who's wanting access to
the information that I share with patients and visits and doesn't live here in BC.
Kim Vopni (48:20.66)
That's amazing. I'll have the links to those in the show notes. That's an incredible resource for people. Thank you for creating that. And thank you so much for being so generous with your time.
Sorry we had some sound issues and technology wasn't necessarily cooperating today, but we managed. We got the information out there. So thank you so much and I really appreciate it.
Dr Carley Akehurst, ND (48:40.797)
You're so welcome, Kim. Thank you for having me. It's a pleasure.
